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Journal of Infant, Child, and Adolescent Psychotherapy, 11:86–95, 2012

Copyright © Taylor & Francis Group, LLC
ISSN: 1528-9168 print
DOI: 10.1080/15289168.2012.676339

Autism Spectrum Disorder in DSM-V: Differential

Diagnosis and Boundary Conditions

Daniel Gensler

This article examines the diagnosis of autism as it has been presented in the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) and is expected to be
presented in the next revision of the DSM. Then I look at the relationship of autism and other labels
and conditions, including Asperger’s disorder, sensory processing disorder, social communication
disorder, mental retardation, social anxiety, obsessive-compulsive disorder, narcissistic disorder of
childhood, and psychosis. I consider how to describe these relationships, looking at concepts of
co-morbidity, overlapping borders, a range of functioning, and changes over time due to therapy,
maturation, and other influences. Two vignettes illustrate these ideas.

There is much to value in being knowledgeable about a diagnostic possibility. It helps to have a
name for what you are dealing with, and diagnostic knowledge provides that name. It supplies
identity, orientation, and a community of other people who are suffering and coping with the
same problem. One diagnosis may be more palatable to one parent than another, allowing the
parent to accept the recommendations that follow from that diagnosis. For example, parents may
prefer one label within the autism spectrum over another because their preferred label does not
feel as stigmatizing or as suggestive of low intelligence. Diagnostic knowledge entitles families to
helpful interventions, especially early intervention in schools, agencies, and at home. Diagnoses
allow application for insurance reimbursement for the cost of these interventions. They also allow
psychiatric researchers to experiment on known diagnostic entities to learn more about cause,
appearance, and treatment. All these benefits require clarity and certainty in the application of
diagnostic knowledge.
On the other hand, diagnostic certainty can go too far. I was once at a conference on autism
spectrum disorders (ASDs) in which one presenter, an expert in the field, joked that for a child

Daniel Gensler is director of training, Child Adolescent Psychotherapy Training Program, William Alanson White
Institute, NY; director of White’s child/adolescent psychology externship; and supervising analyst at White. He was
instructor and supervisor at the Derner Institute of Advanced Psychological Studies at Adelphi University for many
years. He is a co-author of Relational Child Psychotherapy (Other Press, 2002) and has also published a dozen articles and
chapters in the professional literature. He is in private practice doing psychotherapy and psychoeducational evaluations
in Manhattan and Great Neck, NY.
The author would like to thank Ron Balamuth, Nancy Crown, Susan Rose, and Mark Sossin for their helpful com-
ments as he discussed with them the ideas that went into this article. An earlier version of this article was part of an invited
panel, “The Developing Person: Reclaiming Curiosity and Symbolic Meaning in Understanding the Child,” presented at
the spring meeting of Division of Psychoanalysis (Division 39) of the American Psychological Association in New York
on April 15, 2011.
Correspondence should be addressed to Daniel Gensler, 20 Canterbury Road, Great Neck, NY 11021. E-mail:
gen.stein1@verizon.net
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AUTISM SPECTRUM DISORDER IN DSM-V 87

to wear sweat pants is pathognomonic of Asperger’s disorder. To me, wearing sweat pants may
indicate that the child went to gym that day or has a tactile sensitivity as part of a sensory pro-
cessing disorder. Joking about linking sweat pants to an ASD is a way for clinicians who work
with a difficult population to relax. But this kind of joking ignores distinctions that are important
to families and patients and relies instead on current certainties, with the idea that something is
pathognomonic of something else. I have heard other experts in autism say “you know it when
you see it.” Yet Allen Francis, who edited the DSM-IV and is critical of the DSM-V, noted that
diagnostic “concepts are virtually impossible to define precisely with bright lines at the borders”
(Greenberg, 2010).
During the period of a diagnosis’ dominance over clinical thinking, there is an air of authority
and certainty among professionals, as if the diagnosis refers to known truth. Over time, a tension
can develop between current diagnostic categories and facts emerging that will eventually lead
to the next categories. This tension creates conflict between received certainties of diagnostic
authorities and the lived complexity that parents and patients live with, leading eventually to a
revision of the authoritative classification system. Almost 50 years ago, Thomas Kuhn (1962)
described a similar process in the development of scientific thought in his book The Structure of
Scientific Revolutions.
The diagnosis of autism spectrum disorder1 refers to a syndrome that describes individuals
whose interaction, communication, and range of interests are deficient. The causes of autism are
many; genetic, dietary, and psychological sources have been argued for and against. Particularly
interesting to me are ideas about babies’ preference for midrange contingencies (Beebe et al.,
2010) and the early failure in autism (based either in genetics or in very early interaction with
mother) to switch from the preference to explore perfect contingencies to the preference to
explore less-than-perfect contingencies (Gergely, 2001). However, etiology and treatment are
not the subjects of this paper.

AUTISM IN THE DSM

I want to see how the condition has been defined in the DSM and to examine problems with those
definitions. The first edition of the DSM was published in 1952 and the second in 1968. DSM-III
came out in 1980 (revised in 1987), and the fourth and most recent edition was published in 1994
(revised in 2000). DSM-V is scheduled to be released in 2013—all told, more than half a century
of revisions.
In DSM-I (1952), autism was listed under schizophrenic reaction, childhood type (Grinker,
2007). In the second DSM (1968) it was mentioned under schizophrenia, childhood type. In the
third DSM (1980), it received its own diagnosis as infantile autism. When this version of the DSM
was revised in 1987, the diagnosis was called autistic disorder, as it was when the current version,
DSM-IV, was published in 1994 and revised in 2000. In the latest version, autistic disorder is listed
as one of five pervasive developmental disorders (PDD), along with Rett’s disorder, childhood
disintegrative disorder, Asperger’s disorder, and pervasive developmental disorder, not otherwise
specified.
The current structure of the diagnosis, which requires three domains of symptoms, emerged in
the DSM-III-R (third edition, revised) a quarter of a century ago. In the current DSM-IV, the three
domains of symptoms are impairment in social interaction; impairments in communication; and
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88 GENSLER

restricted, repetitive, and stereotyped patterns of behavior, interests, and activities. As is typical
in the DSM, many signs of these symptom domains are listed. In the DSM-IV, six signs of these
three symptom domains are needed (at least two signs from the first domain and at least one each
from the other two domains). The typical age of onset is prior to 36 months.
Current clinical tools used to diagnose autism include the Autism Diagnostic Interview-
Revised (a structured parent interview), the Social Responsiveness Scale and the Childhood
Autism Rating Scale (scales that are filled out by parent, clinician, or teacher based on obser-
vation of the child), and the Autism Diagnostic Observation Schedule (which uses observation
and interaction with the child).
Asperger’s disorder was first introduced into the DSM-IV to describe children who had
symptoms in the first and third domains of the autism triad, namely, impaired social interac-
tion and restricted range of interests, but who did not have impairments in the second domain
of the autism triad, namely, communication. It has been a problematic diagnosis. It is some-
times hard to distinguish Asperger’s disorder from syndromes such as high functioning autism
and Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS), and from other
syndromes such as semantic-pragmatic disorder or nonverbal learning disorder. While children
with Asperger’s disorder may be competent at basic levels of verbal communication, many have
deficits at higher levels of communication, especially in understanding and using language at its
pragmatic level in social discourse. It is unclear whether impairment at this pragmatic level of
discourse should be included under general impairments in communication. If so, impairment
in the pragmatic level of communication would meet the communication deficit criterion for
high-functioning autism, changing the diagnosis from Asperger’s disorder to high-functioning
autism.
The next revision of the DSM, expected in 2013, is expected to solve several of the diagnostic
problems pertaining to autism. First, the term is changed from autistic spectrum disorder to autism
spectrum disorder. The ambiguity concerning Asperger’s disorder will be eliminated in two steps.
The first step is to get rid of the term altogether. The second step is to combine the first two of
the three primary symptom domains of autism spectrum disorder into one symptom domain,
leaving the diagnosis defined by only two symptom domains. The first domain will include both
the first and the second of the former symptom domains, namely, “clinically significant, persis-
tent deficits in social communication and interactions.” No longer will there be the necessity to
decide whether someone can communicate well but relates poorly, as is the current situation with
Asperger’s disorder, because the distinction is collapsed. The other symptom domain is retained,
described as “restricted, repetitive patterns of behavior, interests, and activities,” with two out of
three kinds of symptoms required to make the criterion.
Proposals have also called for a continuum of severity that describes whether the individual
needs support, substantial support, or very substantial support.
In current proposals for DSM-V, not only is Asperger’s Disorder gone but so is childhood dis-
integrative disorder, Rett’s disorder, PDD, and PDD-NOS. Eliminating Asperger’s disorder and
PDD-NOS gets rid of the ambiguities in the diagnosis, but it will have major social implications.
Dropping these terms will affect millions of individuals and their families who have identified
those labels with themselves or their loved ones for the last 20 years. The terms indicate both
what someone is and what someone is not. With the new system, patients and families will have
to grapple with feelings around the word autism, feelings with which they may not have had to
deal because they identified with the other terms. The change in terminology will also require
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AUTISM SPECTRUM DISORDER IN DSM-V 89

school systems and insurance companies to change the systems that link children with diagnoses
to relevant educational services and to reimbursement entitlements.

BOUNDARIES BETWEEN AUTISM AND OTHER DIAGNOSES

Now I want to examine the relationship of autism with other conditions, such as communi-
cation disorder, mental retardation, sensory processing disorder, social anxiety, and obsessive-
compulsive disorder (OCD). In case vignettes, I will also look at the boundaries between autism
and narcissistic disorder of childhood, and between autism and psychosis.

Social communication disorder

In the proposed DSM-V, five new communication disorders are proposed, including one called
social communication disorder. This new disorder would be diagnosed for children with diffi-
culty in the social uses of verbal and nonverbal communication but who do not have restricted
repetitive behavior or activities. Social communication disorder is described as an impairment of
pragmatics. It would be diagnosed based on difficulty in an individual’s social uses of verbal
and nonverbal communication in naturalistic contexts, a difficulty which affects the devel-
opment of social relationships and comprehension of discourse. The difficulty could not be
explained by low abilities in the domains of word structure and grammar or by generally low
cognitive ability. By creating this diagnostic location in the DSM, children with difficulty with
social communication will have their own diagnosis rather than to be thought of as autistic by
default.

Mental retardation (intellectual disability)

The distinction between autism spectrum disorders and mental retardation is complicated. The
new DSM redefines mental retardation as intellectual disability. Intellectual disability is defined
by deficits in two areas, intelligence and adaptive functioning. A person must have deficits in gen-
eral mental abilities of approximately two or more standard deviations in IQ below the population
mean, which refers to an IQ score of approximately 70 or below. There must also be impaired
adaptive functioning in communication, social participation, school or work, or personal indepen-
dence at home or in community settings. The limitations result in the need for ongoing support
at school, work, or independent life.
Here are some of the complications in using this term in relation to autism. Intelligence
testing requires interaction with the examiner, imitation of the examiner, following directions,
understanding and responding to questions, and other skills that may be missing among indi-
viduals who are intelligent but have deficits in relating and communicating (Association for
Science in Autism Treatment, 2011). Further, limited exposure to life reduces familiarity with
facts that are assumed to be commonly known. As a consequence, intelligence testing and
assessment of adaptive functioning can label individuals as intellectually disabled when in fact
test findings are invalid because of the consequences of autism. Further, while the definition
of Asperger’s disorder excludes mental retardation (“there is no clinically significant delay in
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90 GENSLER

cognitive development”), no such exclusion is listed in the current definition of autistic disorder.
With this kind of confusion, studies report large overlap between autistic and mentally retarded
populations. The fraction of autistic individuals who also meet criteria for mental retardation
has been reported as anywhere from 25% to 70%, a wide variation illustrating the difficulty of
assessing intelligence among autistic individuals (Dawson, Mottron, & Gernsbacher, 2008).

Sensory processing disorder

In the DSM-V’s proposed version of autism spectrum disorder, for the first time unusual sensory
behaviors (“unusual reactivity to sensory input or unusual interest in sensory aspects of envi-
ronment”) are listed as one of several criteria for the second domain of symptoms (the domain
describing “restricted, repetitive patterns of behavior, interests, and activities”). Sensory pro-
cessing disorder (formerly called sensory integration dysfunction) has long been known to be
common among autistic individuals but was not given a place in previous versions of this diag-
nosis. Sensory processing disorders refer to individuals who perceive, process, and respond to
sensory information with difficulty. This processing difficulty can lead to severe sensitivity to
sensory input (input from inside the body, and input from the external world), leading to traumat-
ically anxious overstimulation. Symptoms that look autistic can develop as defenses against such
overstimulation, including severe withdrawal; excessive attunement to stimuli; rigid or obses-
sional behavior to feel more in control of experience; and oppositionalism when comfortable
routines are threatened.
Not all individuals with a sensory processing disorder are autistic, and it is unclear whether all
autistic individuals are also troubled with sensory processing problems. However, with the new
DSM there will be a place in the autism diagnosis for the frequent finding of sensory process-
ing problems. Incidentally, sensory processing disorders will still not have their own place as a
distinct diagnosis in the DSM-V.

Social phobia

There is some fuzziness in the distinction between autism and social phobia (also called social
anxiety disorder). Some children are very shy. Some of those are shy temperamentally from
infancy and continue so through childhood. Kagan, Reznick, and Snidman (1988) have demon-
strated that inherited variation in the threshold of arousal in certain limbic sites may contribute
to shyness in childhood and to some of the extreme degrees of social avoidance in adults. Other
children may not be temperamentally shy but have learned to withdraw from social interaction
because a disabling condition has led them to be teased or bullied. This can occur in the case of
children with cerebral palsy, for example, or children who stutter. When shy children stay with-
drawn, they do not practice social skills, and as a consequence they can become awkward in their
actual interaction with others. Very shy children can fail to develop peer relations and can stop
trying to share their interests with others.
When a parent describes this social awkwardness or when it is apparent in the office, a clinician
might think of the first domain of autism—that of impairment of social interaction. In DSM-IV,
two of four symptoms must be present to imply a qualitative impairment in social interaction.
These four symptoms are:
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AUTISM SPECTRUM DISORDER IN DSM-V 91

1. Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze,
facial expression, body postures, and gestures to regulate social interaction.
2. Failure to develop peer relationships appropriate to developmental level.
3. Lack of spontaneous seeking to share enjoyment, interests, or achievements with other
people (e.g., by a lack of showing, bringing, or pointing out objects of interest).
4. Lack of social or emotional reciprocity.

When shy children fail to develop peer relations and stop trying to share their interests with others,
these two symptoms are enough to achieve the autism spectrum diagnosis’ criterion for qualitative
impairment in social interaction, even though the symptoms may reflect shyness or social anxiety
rather than an autistic problem. If such a child also has a restricted range of activities, then
autism spectrum diagnoses might be considered. Arriving at such diagnoses, however, does not
give sufficient attention to the distinction between the effects of shyness and social phobia on the
one hand and primary impairment of social interaction on the other.
The DSM-V does not solve this problem. To make this distinction, a clinician should take into
account a socially withdrawn child’s ability or lack of ability to recognize that another person has
his or her own point of view, that is, whether such a child has a working “theory of mind” (Baron-
Cohen, Jolliffe, Mortimore, & Robertson, 1997). A clinician should also consider whether such
a child can be compassionate or empathic with others, whether such a child can be funny, and
whether such a child can take a realistic perspective on himself or herself. If a socially withdrawn
child, even a child who also has a restricted range of interests, has a theory of mind, can be
empathic with others, is funny, and can take a realistic perspective on himself or herself, than the
autism diagnosis is less likely to be relevant.
Further, the DSM-IV’s idea of “primary impairment of social interaction,” or the DSM-V’s
idea of “persistent deficits in social communication and social interaction,” needs to be fur-
ther specified. For example, one parent scale, the Social Responsiveness Scale (Constantino and
Gruber, 2005), distinguishes five focuses for psychotherapy regarding improving social deficits:
social awareness, or picking up on social cues; social cognition, or interpreting social cues
once they are picked up; social communication, or behaving in a socially reciprocal way; social
motivation, or desire to engage in social behavior; and autistic mannerisms, or the restricted or
stereotypical behaviors and interests typical of autism. When a child who is said to have autism
is seen as having a primary impairment or a persistent deficit in social interaction, is the impair-
ment in social awareness, cognition, communication, or motivation? The proposed DSM-V does
not answer this question, but it does require three symptoms (not just two) as criteria of deficits
in social communication and interaction. It has also dropped the confusing symptom of “lack of
spontaneous seeking to share enjoyment, interests, or achievements,” which can also appear with
social anxiety. Hopefully this change will reduce the number of times that primarily shy children
will wrongly be seen as autistic.

Obsessive-compulsive disorder

I have spoken about distinctions between autism and sensory processing disorder, Asperger’s
disorder, social communication disorder, and social anxiety. I turn briefly now to obsessive-
compulsive disorder (OCD). The diagnoses of OCD and autism both require the presence of
recurrent and persistent thoughts or behaviors. Yet in OCD the recurrent thoughts cause anxiety,
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92 GENSLER

and in autism this is not necessarily the case, or it is hard to know if this is the case. Further, in
autism there must also be impairment in socialization and communication, whereas this is not
required for the OCD diagnosis.

PROBLEMS IN THE CONCEPTION OF DIAGNOSIS

AS A CATEGORY

DSM-V has solved certain conceptual problems with the autism diagnosis by doing away with
the ambiguities of the Asperger’s disorder label (although this solution has created other prob-
lems); by distinguishing social communication disorder as a separate diagnosis; and by including
sensory processing disorders within the autism diagnosis. DSM-IV is already capable of dis-
tinguishing autism from OCD. Problems remain in the proposed definitions in DSM-V in
distinguishing autism spectrum disorders from mental retardation and social phobia.
I want to propose a different way to think about diagnosis. So far, we have the possibilities
of a single diagnosis, several co-morbid diagnoses, or a diagnosis that is not otherwise specified.
Yet it is common for symptoms to rise and fall in frequency and intensity and to change in their
nature over time. Children often go through a round of diagnostic possibilities over a week’s or
a month’s time, including healthy periods. Rather than to feel obliged to say what the child “is”
diagnostically, it makes more sense to me to see diagnosis as a range or a cycle over time, to use
a temporal metaphor, or as an overlap of diagnostic boundaries, to use a spatial metaphor. This
point of view also allows for periods or moments of normal or better than normal functioning,
rather than to have to refer to “splinter skills” in a child who is “really” autistic.

Two vignettes

I want to apply this kind of thinking to two cases, one at the boundaries between Asperger’s dis-
order, obsessive-compulsive disorder, and narcissistic disorder; the other at the boundary between
autism spectrum disorder and psychotic disorder.
The first vignette is of a 10-year-old boy whose functioning varies between narcissistic
pathology, obsessional-compulsive problems, and Asperger’s disorder. Regarding narcissistic
pathology, he is inflexible and needs to win. He lies to make himself look more important. He
will either cheat or walk away if he loses, and he avoids dealing with conflict. He resists learning
because he feels humiliated by the experience of not already knowing. As a consequence he says
“I know, I know,” but he does not take in explanations or instruction. He does poorly with peers
who are strong-willed, preferring to play with children with whom he can control the conversa-
tion or interaction. He prefers to relate individually to the youngest or most immature child. He
wants to feel special and he brags about his skills, without recognizing how irritating this behav-
ior can be to others. This boy frequently experiences intolerably low self-esteem that is triggered
by ordinary daily events. He defends against the painful feeling of low self-regard by cheating,
bragging, walking away, and avoiding certain learning situations.
He also needs things to be just so during nighttime rituals; he has trouble with changes of
routine; he imitates airplane noises when he is alone; and he has a compulsive habit of anal
scratching through his clothes.
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AUTISM SPECTRUM DISORDER IN DSM-V 93

He is fine socially with adults, but in his relationships with other children he is often weak in
social pragmatics. He has trouble reading social nuances, blurts out personal questions without
regard for the feelings of the child he is asking the question of, and brags or lies without regard
for its effect on others. He can tolerate the flow of conversation when he can control it, but gets
passive or withdrawn when he cannot.
By looking at his symptoms through the point of view of the autism spectrum, he looks like
children with Asperger’s disorder, with repetitive restricted patterns of activity, and limitations
in social pragmatic ability. Further, on standard parent questionnaire scales, he looks autistic.
I asked his parents to complete the Social Responsiveness Scale. Each parent placed him highest
in autistic mannerisms and in social cognition (father’s ratings placed him in the severe range,
mother’s ratings placed him in the mild to moderate range), and his father placed him in the
mild to moderate range on the other three scales. Such scores are supposed to be strongly associ-
ated with a diagnosis on the autism spectrum, suggesting severe interference in everyday social
interactions, especially in the eyes of the boy’s father.
Yet his various symptoms rise and fall in frequency and intensity over the course of time. He
seems to go through a round of diagnostic possibilities over a week’s time, variously looking
normal, narcissistic, Asperger’s, and obsessive-compulsive. While the DSM-IV standby term,
“Not Otherwise Specified,” is accurate, it is hardly specific. Using the metaphor of space instead
of time, his functioning overlaps the boundaries between these diagnoses and normality. The
term co-morbidity is not sufficient because it suggests the presence of two distinct diagnoses
rather than to indicate change over time or motion across diagnostic borders.
I want to examine this idea of ranging in time and space across diagnostic boundaries by look-
ing at one more case, a girl with features of Asperger’s and psychotic disorder. I supervised the
case. The girl was 7 years old at the start of therapy. She was afraid of social interaction and
preoccupied with fantasy. She was bilingual (her parents were Chinese), highly verbal and intel-
ligent, had good artistic ability from an early age, and read early. Her therapist was from China as
well, and the therapy was conducted in Mandarin. By the age of 6 she was preoccupied with her
stuffed dogs, drawing pictures and telling imaginary stories about them. At the same time, she
was averse to going outdoors because she was afraid of seeing her acquaintances. Specifically,
she was afraid that they would call her by name, or that they would express praise for her if she
looked good or did something well, or that they would express concern for her if she had been
absent or sick. She felt assaulted when others would recognize, praise, or express concern for
her. She had her stuffed animal bark at people or she would have it pretend to bite other people
when they did these things in order to defend herself. She did not try to understand why other
children would say hello to her, praise her, or show concern for her. She could not imagine how
upset or confused her acquaintances felt when she had her stuffed dog bark at them or pretend to
bite them.
The therapist returned to China after a year, after transferring her patient to another Chinese
therapist with whom therapy continued. In the course of the year, the girl made some progress
in developing a theory of mind, empathy for others, and reflecting on her own experience.
Therapeutic progress presents a challenge to diagnosis.
In the DSM-IV the diagnosis of paranoid schizophrenia requires a preoccupation with delu-
sions or hallucinations. Behavior and speech are not otherwise disorganized, and affect is neither
flat nor inappropriate. For any kind of schizophrenia, when the onset is in childhood or ado-
lescence, there is a failure to achieve expected level of interpersonal or academic achievement.
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94 GENSLER

If there is a co-occurring autism or another pervasive developmental disorder, the additional diag-
nosis of schizophrenia can be made if there are delusions or hallucinations that have been present
for at least a month. If delusions last six months and the other conditions just described are
present, then the diagnosis of paranoid schizophrenia can be made.
This little girl had the delusional belief that other children were dangerous and needed
to be barked at when they greeted, praised, or expressed concern for her. Her condition had
lasted longer than six months and caused a major interference in her interpersonal functioning.
Therefore, she could be said to have paranoid schizophrenia. Concurrently, she could be diag-
nosed with Asperger’s disorder because of her impairment in social interaction and her restricted
repetitive and stereotyped patterns of behavior, interests, and activities.
Rather than to decide if this girl was psychotic, had Asperger’s disorder, or both, I find it
more accurate and useful to discuss a continuum along which she functions, with diagnostic
considerations placed variously

• between or among several diagnostic categories

• at a metaphoric spatial boundary between these possibilities
• at an overlapping of these diagnoses
• on a range that changes over the short term of a week or a month
• on a range that changes over the long term.

Such long-term changes can occur through maturation or regression, variation in external stresses,
new developmental challenges or changes in life’s circumstances, or therapy. For the girl in the
second case vignette, for example, diagnosis seen in this way would range between Asperger’s
disorder and paranoid psychotic functioning; forward to more health and backward to worse
functioning, over the short run; and forward to more health, over the long run.

SUMMARY

Diagnoses are useful when we are pressed by the needs of identity, community, entitlements,
reimbursement, treatment, or research. However, settling on a categorical diagnosis can come at
the expense of the complexity that people actually live with. For lay people, it may sometimes
be more useful to call an experience a nervous breakdown rather than to use the diagnostic terms
of major depressive episode or psychotic break; the loss of clarity is made up for by the truth-
fulness of the ambiguity of whatever happened (Carey, 2010). For clinicians, it may sometimes
be more useful to remain less certain of a single diagnosis and more open to this ambiguity and
complexity. Seeing diagnosis on several dimensions, as described in this paper, might help us
orient ourselves and our patients better to this kind of complexity, both for the autism spectrum
and for other diagnostic categories.

NOTE

1. I use the DSM-V term autism spectrum disorder in this article rather than the DSM-IV term autistic spectrum disorder.
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AUTISM SPECTRUM DISORDER IN DSM-V 95

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